Surgical Management of Peripheral Vein Thrombophlebitis in the Upper Extremity.

Purpose: Peripheral vein thrombophlebitis has a reported overall incidence ranging from 20% to 80%. Thrombophlebitis can progress despite antibiotic therapy to become a challenging clinical problem requiring surgical intervention. There is currently no consensus on its optimal management. We reviewed our experience of surgical intervention with analyses of the indications for intervention, descriptions of the surgical procedures, and outcomes. We aimed to provide guidance on the management of this potentially serious complication. Methods: This is a retrospective review of 51 patients with thrombophlebitis refractory to conservative management between January 2017 and August 2020. Results: Analyses revealed a high prevalence of comorbidities, including diabetes mellitus, malignancy, and chronic kidney disease. A total of 60% of patients had concurrent bacteremia, and the decision to operate had a low threshold in the presence of these factors. On exploration, 80% of patients had intraluminal thrombus, 47% had intraluminal pus, and 29% had pus beyond the veins or extending proximally. The surgical approach employed in 98% of patients involved an extensile incision in those with several morbidity factors (diabetes mellitus, chronic kidney disease, or bacteremia). One patient presented with severe clinical signs of local infection, and on exploration, there was intraluminal pus and thrombus up to 10 cm. A novel technique of a minimally invasive approach of intermittent stab incisions was employed in a young and healthy patient without comorbidities. Conclusions: We developed an algorithm to guide the indications for intervention and surgical approach to thrombophlebitis. The threshold for intervening surgically should be lowered by the presence of comorbidities. The failure of antibiotics to resolve the clinical signs of infection or the suspicion of abscess formation should mandate intervention. Thrombosed sections of the vein should be ligated proximally and distally and excised and surrounding collections of pus drained. Delayed secondary wound closure is usual. Stab incisions may limit surgical dissection and subsequent scarring in less severe cases. Type of study/level of evidence: Prognostic IV.

Hand Surgery in Singapore.

Singapore as an island nation is one of three countries in the world that has hand and reconstructive microsurgery (HRM) as an independent specialty. The 52 accredited hand surgeons serving a population of 5.7 million facilitate hassle free access to patients. Hand surgery historically is rooted very much in orthopaedic surgery as in most Asian countries with more than five decades of rapid evolution. Singapore pioneered a structured and systematic training program for HRM and the local surgeons have contributed significantly to the body of knowledge in hand surgery with targeted research and publications with three surgeons being awarded international recognition for their contributions. Singapore continues to contribute significantly to surgical volunteerism regionally through active involvement in the training of regional surgeons through their sustainable volunteer activities and through international fellowships in Singapore hospitals. The future of hand surgery in Singapore will be more competency and multidiscipline based on community-centered approach.

Concomitant Lipoma and Ganglion Causing Ulnar Nerve Compression at the Wrist: A Case Report and Review of Literature.

We present a rare case of ulnar nerve compression caused by concurrent lumps-a lipoma and a ganglion at the wrist, with no prior report cited in the English literature. This case illustrates the possibility of dual concurrent pathologies causing ulnar neuropathy and the importance of not missing one.

Surgical treatment for total root avulsion type brachial plexus injuries by neurotization: a prospective comparison study between total and hemicontralateral C7 nerve root transfer.

PURPOSE: We conducted a clinical study to evaluate the effects of neurotization, especially comparing the total contralateral C7 (CC7) root transfer to hemi-CC7 transfer, on total root avulsion brachial plexus injuries (BPI). METHODS: Forty patients who received neurotization for BPI were enrolled in this prospective study. Group 1 (n = 20) received hemi-CC7 transfer for hand function, while group 2 (n = 20) received total-CC7 transfer. Additional neurotization included spinal accessory, phrenic, and intercostal nerve transfer for shoulder and elbow function. The results were evaluated with an average of 6 years follow-up. RESULTS: Group 1 had fewer donor site complications (15%) than group 2 (45%); group 2 had significantly better hand M3 and M4 motor function (65%) than group 1 (30%; P = 0.02). There was no difference in sensory recovery. Significantly, better shoulder function was obtained by simultaneous neurotization on both suprascapular and axillary nerves. CONCLUSIONS: Total-CC7 transfer had better hand recovery but more donor complications than hemi-CC7. Neurotization on both supra-scapular and axillary nerves improved shoulder recovery.

Comparative study of outcomes between pollicization and microsurgical second toe-metatarsal bone transfer for congenital radial deficiency with hypoplastic thumb.

With the advent of microsurgery, various surgical options exist to treat the hypoplastic thumb in patients with radial deficiency. This study aims to compare the outcome assessments between index finger pollicization and microsurgical second toe-metatarsal bone transfers for thumb reconstruction in these patients. Between 1996 and 2002, a total of 30 patients were included and equally divided into two groups: Group 1 (pollicization) and Group 2 (toe transfer). The mean patient age was 3.2 years, and the mean duration of follow-up was 8 years. The average operation time was 2.6 hours and 8.0 hours for Group 1 and Group 2, respectively. The success rate of thumb reconstruction was 100% in both groups. All the children achieved both small and large grip functions as well as complete sensory recovery. Patients who underwent pollicization had earlier motor and sensory recovery and better range of motion; whereas, patients who received toe transfers had higher parental satisfaction and performed better in some activities of daily living.

Outcomes of open carpal tunnel releases and its predictors: a prospective study.

A prospective study of 74 patients who underwent open carpal tunnel releases was conducted, with a follow-up period of six months. We analyzed multiple preoperative variables in order to identify factors that might predict outcomes. These outcomes included improvement in symptom severity and functional severity scores, grip strength as well as patient satisfaction. All the patients showed improvement in symptoms with 72% showing complete symptomatic relief, 74% showing improvement in function and 66% showing improvement in grip strength, and 82% were either completely or very satisfied with the results of surgery. Older patients and patients with weakness were associated with poorer outcomes. Higher preoperative symptom severity and functional severity scores were also associated with less improvement in symptoms and function, respectively. This information would benefit the surgeons and patients during preoperative counseling and help facilitate the decision-making process for both parties.

Spontaneous partial posterior interosseous nerve palsy not caused by an adjacent ganglion.

We report a case of spontaneous partial posterior interosseous nerve palsy where the ganglion adjacent to the nerve was not the main cause of the compression. Instead, a thick fascial band deep to the distal edge of the supinator was found responsible. This case illustrates the importance of completing the nerve exploration to fit with the clinical picture.